Affirmation and Disclosure Form 4-17-24 Fill In.pdf
PDF 91 KB Posted
- Solicitation number
- SRC0000023413
- Issued by
- Putnam County, Ohio
About this file
This document is an Affirmation and Disclosure Form required for a state and local contract opportunity. The form requires the contractor to disclose the principal location of their business, the locations where services will be performed, and the locations where state data will be stored, including any subcontractor information. The contractor must affirm that they have read and understand the applicable Executive Orders regarding the prohibitions of offshore services, offshore data storage, and purchasing from Russian institutions or companies. The contractor must also agree to immediately notify the State of any change or shift in the location of services performed during the contract.
The form does not provide details about the specific contract opportunity, such as the products or services requested, project overview, response dates, award information, or contract term. It focuses solely on the location and data storage requirements that the contractor must disclose and affirm as part of the contracting process.
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Text version
AFFIRMATION AND DISCLOSURE FORM
Rev. 3/22 Page 1 of 2
Contractor affirms that Contractor has read and understands the applicable Executive Orders regarding the prohibitions of performance of offshore services, locating State data offshore in any way, or purchasing from Russian institutions or companies.
Contractor shall provide all the name(s) and location(s) where services under this Contract will be performed and where data is located in the spaces provided below or by attachment. Failure to provide this information may result in no award. If the Contractor will not be using subcontractors, indicate “Not
Applicable” in the appropriate spaces.
1. Principal location of business of Contractor:
(Address) (City, State, Zip)
Name/Principal location of business of subcontractor(s):
(Name) (Address, City, State, Zip)
2. Location where services will be performed by Contractor:
Name/Location where services will be performed by subcontractor(s):
Rev. 3/22 Page 2 of 2
3. Location where state data will be located, by Contractor:
Name/Location(s) where state data will be located by subcontractor(s):
Contractor affirms, understands, and agrees that Contractor and its subcontractors are under a duty to disclose to the State any change or shift in location of services performed by Contractor or its subcontractors before, during and after execution of any contract with the State. Contractor agrees it shall so notify the
State immediately of any such change or shift in location of its services. The State has the right to immediately terminate the contract, unless a duly signed waiver from the State has been attained to perform the services outside the United States.
On behalf of the Contractor, I acknowledge that I am duly authorized to execute this Affirmation and
Disclosure Form and have read and understand that this form is a part of any Contract that Contractor may enter into with the State and is incorporated therein.
By:
Contractor
Print Name:
Title:
Date:
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File details come from the government source that posted it. Updated .